Provider Demographics
NPI:1073856043
Name:O'CONNOR, TIMOTHY ISAMU (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ISAMU
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:
Practice Address - Street 1:55 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4445
Practice Address - Country:US
Practice Address - Phone:509-525-3720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60368579208000000X
WAMD60658842208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics